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Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).<\/jats:p><\/jats:sec><jats:sec><jats:title>Objective<\/jats:title><jats:p>To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline\u2010concordant antibiotic prescribing for pneumonia in the pediatric ED.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Pragmatic randomized clinical trial.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting and Participants<\/jats:title><jats:p>Encounters for children (6 months\u201018 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.<\/jats:p><\/jats:sec><jats:sec><jats:title>Intervention<\/jats:title><jats:p>CDS or usual care was randomly assigned during 4\u2010week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main Outcome and Measures<\/jats:title><jats:p>The primary outcome was exclusive guideline\u2010concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3\u2010 and 7\u2010day revisits.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline\u2010concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre\u2010specified stratified analyses, CDS was associated with guideline\u2010concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; <jats:italic>p<\/jats:italic> = .024). There were no differences in safety outcomes.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Effectiveness of ED\u2010based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.<\/jats:p><\/jats:sec>","DOI":"10.1002\/jhm.13101","type":"journal-article","created":{"date-parts":[[2023,4,12]],"date-time":"2023-04-12T09:06:58Z","timestamp":1681290418000},"page":"491-501","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Antibiotic clinical decision support for pneumonia in the ED: A randomized trial"],"prefix":"10.1002","volume":"18","author":[{"given":"Derek J.","family":"Williams","sequence":"first","affiliation":[{"name":"Monroe Carell Jr. Children's Hospital at VUMC Vanderbilt University School of Medicine Nashville Tennessee USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Judith M.","family":"Martin","sequence":"additional","affiliation":[{"name":"UPMC Children's Hospital of Pittsburgh 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